ISSUES AND PRIORITIES
Prepared in May 2008 by
The IVIissouri IMental Health Commission
Dr. Ron Dittemore, St Joseph, Chair
Dr. Patricia Bolster, St Louis Ms. Kathy Carter, Four Seasons Ms. Beth Viviano, St Louis
Rev. Phillip McClendon, Joplin Dr. David Vlach, Kansas City Ms.Joann Leykam, St Charles
Four Major Issues
Mental Health Transformation
The Missouri Mental Health Commission is a Governor-appointed, non
partisan, seven-member board statutorily established (Chapter 630.003,
RSMO) with executive and policy oversight for the Missouri
Department of Mental Health (DMH).
During times of gubernatorial transition, the Commission provides
information to candidates, without consideration of political affiliation,
regarding the DMH mission, its programs, key issues and a vision for
Missouri mental health in the future.
Commission members and DMH staff
are available for discussion about the
contents of this document or mental
health issues in general upon any
candidate 's request, which should be
made at the following e-mail site:
II. CRITICAL POINTS
1. The Department of Mental Health (DMH) proudly serves over 170,000
Missourians with mental illness, developmental disabilities, and addictions.
It is a safety net for the state's most vulnerable citizens and their families.
2. Only about 5% of DMH consumers are served in state-operated facilities.
Most are served through 1,600 contracts with community-based providers.
DMH employs about 8,800 professionals and other workers, while its
contractors employ over 30,000 Missourians.
3. DMH has heavily leveraged state dollars to draw federal match through MO
HealthNet and federal grant programs in order to optimize resources. In fact,
only 53% of the department's $1.1 billion budget is General Revenue.
4. Too many citizens cannot access DMH services. Each of the Department of
Mental Health's three operating divisions has long waiting lists for services and
supports. Every name on a waiting list is a potential tragedy.
5. Missouri's mental health workforce is critically low. There are not enough
mental health professionals or direct care staff to fill positions in state -run
facilities or contracted community agencies. High turnover rates at all levels,
from physicians to food service workers, threaten the safety of consumers and
6. Contracted community provider reimbursement rates have lagged far
behind inflation. Providers struggle to meet costs for food, fuel, insurance,
and proper staffing.
7. State-run psychiatric facilities continuously operate above patient capacity.
Long-term care facilities and the sexual offender treatment center are
particularly strained in that there are inadequate (or absent) community
alternatives along with limited ability to control admissions and discharges.
III. DMH OVERVIEW
A. DMH MISSION (RSMO Chapter 630.020)
1. Prevention: Reduce the prevalence of mental disorders, developmental disabilities,
and drug abuse;
2. Treatment: Operate, fund, and license modem treatment and habilitation programs
provided in the least restrictive environment; and
3. Improve Public Understanding: Improve public understanding and attitudes
toward mental illness, developmental disabilities, and addiction.
MISSOURI DEPARTMENT OF
B. DMH VISION Missourians receiving mental health services will have the
opportunity to pursue their dreams and live their lives as valued members of their community.
a DMH DIVISIONS AND OFFICES
• Alcohol and Drug Abuse (ADA) -RSMo Chapter 631
• Comprehensive Psychiatric Services (CPS) —RSMo Chapter 632
• Mental Retardation and Developmental Disabilities (MRDD) —RSMo Chapter 633
Office of Comprehensive Child Mental Health -RSMo 630.1000
Office of Transformation - Governor appointed and time limited
D. DMH CONSUMERS
DMH served 171,208 people in community settings and 8,748 in institutional settings in FY
2007 (duplicated counts).
• Adults with severe mental illness and children with severe emotional disorders
• People with developmental disabilities
• People with substance abuse and gambling disorders
• Sexually violent predators
About half of the individuals served by DMH are Medicaid eligible.
E. DMH FUNDED AND OPERATED PROGRAMS
Annual budget: $1.1 billion: 53% GR, 43% Federal, 4%) Other Funds
DMH generates $185 million per year in reimbursements from Medicaid, Medicare and other
third party pay, as shown below (does not include the $92 million disproportionate share payments [DSH]
retained by the Department of Social Services):
Other 3"^ party/client pay
Amount of State General Revenue that matches Medicaid entitlement services: $157,028,754
(does not include DMH GR that generates $134 million in DSH payments to DMH and DSS).
Community-Based Contractual Services:
DMH contracts with over 1,600 providers employing 30,000 people statewide.
State-operated services: 8,800 state employees
9 state psychiatric facilities for adults
2 state psychiatric facilities for children
6 MRDD habilitation centers, 1 1 regional centers
Certification and Licensure:
> Certities 674 community providers.
> Licenses 405 community facilities and programs.
• Community-based services
contracts are 67%) of total
budget and serve 95% of
• State operated services are
27% of the total budget and
serve 5% of DMH consumers.
• Due to lack of adequate funding, DMH-contracted
community mental health centers (CMHCs) turn away 2,000
people per month in need of mental health treatment who are
without insurance or MO HealthNet coverage.
Access to Mental
• Most DMH psychiatric hospitals typically operate at
108-1 15% over census. Western Missouri Mental Health
Center's emergency room has been on diversion for 360 of
the last 365 days.
• Only 8% of the estimated 485,000 Missourians with substance abuse problems were treated
by the Division of ADA in FY 2007. A snapshot of waiting lists on one day in 2007 found
over 3,000 people waiting for ADA services.
• One in 150 Missouri children will be diagnosed with Autism.
• MRDD case managers have caseloads as high as 70 clients in many areas of the state.
• 4,000 eligible individuals still await MRDD in-home or community residential services.
• On average, Missourians with serious mental illness die 25 years earlier than the general
population; 60% will die from a chronic medical condition, not from self-harm.
• Missourians with developmental disabilities die 12-16 years earlier than the general
• 25% of all U.S. community hospital admissions for adult patients involve serious mental
illness and substance abuse.
• 16% of all Department of Corrections (DOC) inmates are diagnosed with mental illness, and
85%) have substance abuse problems.
• State psychiatric facilities are seriously overcrowded
because of few community alternatives and limited ability to
control admissions and discharges.
• Courts control 7 of 10 admissions to DMH long term
care state hospital beds [Incompetent to Stand Trial (1ST),
Not Guilty By Reason of Insanity (NGRI), or sexual
predators (Missouri Sexual Offender Treatment Program —
• Courts also control forensic discharges from state
facilities to community settings or jail for individuals found
competent to stand trial for an alleged crime.
"If we cannot control the front end or the back end of our institutional services,
our only choices are to add more beds and resources or dilute the quality of care
until we experience crises in safety for patients and staff "
— Dr. Joe Parks, DMH Medical Director and
Director, Division of Comprehensive Psychiatric Services
• Overcrowding of State Facilities: State psychiatric hospitals operated at 108-1 15%
capacity in FY 2007.
• Client Injuries: In the past year there were 5,244 injuries requiring at least first-aid to
clients in DMH facilities; 633 of these required medical intervention beyond first-aid.
• Staff Injuries and Workers Compensation: For Fiscal Years 2005 (1,559), 2006 (1,718)
and 2007 (1,756), DMH staff reported a total of 5,033 injuries to Worker's
Compensation. Of these, 60% were client related.
3. Workforce Shortage and Low Reimbursemen t Rates Pose
Significant Challenges to Care and Safety
• Department-wide (State Psychiatric Hospitals and MRDD Habilitation Centers) vacancy
and turnover rates in key direct care and clinical staffing positions:
Annual Turnover Rate
• DMH contracted community providers serve 95% of all DMH consumers. Over the last
15 years, community provider rates have not kept pace with inflation. Community
providers cannot compete with the private sector or even state salaries. Costs of
medicine, food, transportation and communication far exceed inflation rate adjustments.
• Disparity examples: State employee COLAs (salary and fringe) increased 49.7%
between fiscal years 1999 to 2008 compared to 1 1.6% for ADA provider COLAs, 1 l.P/o
for CPS provider COLAs, and 30% for MRDD provider COLAs.
• Federal reimbursement rates for Federally Qualified Health Centers (FQHCs) for many
behavioral health services are nearly twice that received by community mental health
• Facility staff overtime is too high. DMH paid overtime trends: $11 million in FY 05 to
$13 million in FY 07.
• Facility staff morale is low due to mandatory overtime and a feeling that nothing is
• Facility direct care staff view their positions as dead-end jobs with no career
• Facility sick leave is too high, with some staff manipulating Family Medical Leave.
• Contracted community providers are in much the same predicament:
- Unable to compete with private sector for professionals and direct care workers
- High turnover, low morale
- Unable to keep pace with rising food, fuel, and insurance costs
• DMH must transform its current system from
crisis-driven care toward a public health approach that
emphasizes wellness, prevention, disease management,
and early intervention.
• Missouri's autism treatment services for young
children must be greatly expanded, in collaboration with
school-based autism services.
• Missouri lacks full insurance parity for the
treatment of either mental illness or addiction, and there is
an urgency from families seeking insurance coverage for
Employment opportunities are
scarce for DMH consumers.
- Persons with serious mental illness and developmental disabilities generally live in
- Only 16.5% of individuals with serious mental illness worked during 2006.
- There is a 40% gap between the employment rate of adults with disabilities and those
without disabilities. Half of Missouri's homeless have serious mental illness or
• Current system is limited to costly "deep-end" behavioral services available only to the
sickest Missourians, predominately individuals that are MO HealthNet eligible. Disabled
recipients are among the most expensive of the MO HealthNet program.
• All three operating divisions have long waiting lists for services. Those lists could be
reduced with proper preventive services and early intervention.
V. MENTAL HEALTH TRANSFORMATION
• In October 2006, Missouri received a five-year grant from the federal Substance Abuse and
Mental Health Services Administration (SAMHSA) Mental Health Transformation State
Incentive Grant program to develop and implement a comprehensive plan to transfr)rm the
mental health system in Missouri.
• Executive Orders 06-39 and 07-15 established the Transfr)rmation Working Group (TWG),
comprised of consumer and family leaders and public leaders from the executive and judicial
• Staff based in the Department of Mental Health (DMH) led the planning process in
partnership with other state agencies involved with mental health services.
• The Comprehensive Plan, submitted to SAMHSA in March 2008, is designed to move
Missouri's mental health system toward a public health approach. It addresses mental health
services and access across systems, age groups, cultures and regions.
• The common agenda that emerged to achieve the shared vision and move Missouri toward a
public health approach resulted in six strategic themes:
CULTURE OF CRISIS/
RISK OF HARM
CULTURE OF HOPE/
FIRST.. ."DO NO HARM"
"NOWHERE TO GO"
EASY, EARLY AND
WELLNESS FOCUS WITH
PREVENTION AND EARLY
PROVIDER DRIVEN CARE
SHARED OWNERSHIP &
VI. RECENT ACHIEVEMENTS: Highlights from
FY 2005 - 2007
1. CHILDREN RETURNED TO MOTHERS' CUSTODY: 246 children were returned to their mothers'
custody through ADA's specialized CSTAR substance abuse programs for women with children.
2. DRUG-FREE BIRTHS: 266 drug-free babies were bom to pregnant drug-addicted women through
ADA'S CSTAR programs.
3. CUSTODY DIVERSION FOR SED CHILDREN : 386 children with Serious Emotional Disorders
(SED) have been able to remain in the custody of their families and still receive intensive mental health
services through the — Qstody Diversion Protocol " developed by DMH as part of the Comprehensive
Children's Mental Health Plan.
4. MISSOURI DMH/MO HEALTHNET PHARMACY IMPROVEMENT PARTNERSHIP: The
DMH and MO HealthNet Partnership Initiative improved prescribing practices for psychiatric medications
for enrollees and saved $36 million per year off projected growth trends. The Initiative is nationally
recognized and is the only state program to have won the American Psychiatric Association Bronze
5. WAITING LISTS FOR MRDD SERVICES: More than 847 children and adults with developmental
disabilities who were previously on the MRDD wait list are now receiving services.
6. COMMUNITY TRANSITION: MRDD has successfully transitioned 238 individuals to community
living environments from its six habilitation centers since January 1, 2005.
7. MISSOURI'S NATIONAL LEADERSHIP IN AUTISM : Missouri is a national leader in the
development of an Autism Registry through the Interactive Autism Network (lAN)-MO project, a
partnership between DMH-MRDD, the Thompson Center for Autism, and Kennedy Krieger Institute in
8. CRISIS INTERVENTION TEAMS: 1,500 local police officers statewide have voluntarily participated
in Crisis Intervention Team (CIT) training, helping them to better respond to persons with mental illness
and getting them to treatment instead of jail. Officers have made more than 7,400 mental health crisis calls
with an arrest rate below 5%.
9. FEDERAL GRANTS: With help from the Missouri Institute of Mental Health (MIMH), Missouri ranks
8* in the country for competitive grant funding from the Substance Abuse and Mental Health Services
10. SUICIDE PREVENTION TRAINING: DMH has sponsored training for more than 15,000 Missourians
to help them recognize suicide risk and to assist people who may be considering suicide get treatment.